Non-Communicable Diseases and National Health Program (NCD)

NON-COMMUNICABLE
DISEASES AND NATIONAL
HEALTH PROGRAM (NCD)
Shashi Prakash
Tutor
College of Nursing,
S. N. Medical College

LEARNING OBJECTIVE
At the end of the lecture, students will be able to
describe:
 how to use epidemiology to address a public
health problem.
 The burden of disease of the 4 main
Noncommunicable Diseases (NCDs), and
 How risk factors affect the burden of NCDs.

 Definition and approaches of epidemiology
 Public health management cycle
 Core functions of epidemiology
 Basic terminology
 Definition and characteristics of NCDs
 Global trends in NCDs
 Definition of risk factors and metabolic risk
factors
 Comparison of non-communicable diseases
and communicable diseases

Common risk factors for NCDs
More in-depth discussion on 4 leading NCDs, 4
behavioral/lifestyle risk factors, and 4 metabolic
risk factors
o Definition
o Global burden
o Health effects
 NPCDCS and NCD program in India

DEFINITIONS AND
APPROACHES OF
EPIDEMIOLOGY

Non-Communicable Diseases and National Health Program (NCD)

EPIDEMIOLOGY: CDC
DEFINITION
 “The study of the distribution and determinants of health-related
states in specified populations, and the application of this study to
control health problems.”
 Distribution Determinants
 Health-related States specified Population Application
(Last, 2001)

Example: According to a study of deaths in Country X in
2008, 1,034 cervical cancer deaths occurred among
women between the ages of 45-54.
Distribution: Occurrence of cases by time, place, and
person
Definition Distribution

Example: Smoking was a risk factor or
determinant for the greater number of cancer
deaths among women ages 45-54 in Country X.
Determinants: All the causes and risk factors for the
occurrence of a disease, including physical, biological,
social, cultural, and behavioral factors

Health-related states
•Diagnosis of a specific disease or cause of
death
•Health-related behavior (e.g., smoking, taking
prenatal vitamins)
•Example: According to the 2008 study in
Country X,1,034 cervical cancer deaths
occurred among women between the ages of
45-54.

EPIDEMIOLOGY: CDC
DEFINITION SPECIFIED
POPULATION
Specified Population: A measurable group, defined
by location, time, demographics, and other
characteristics
Example: Women aged 45-54 living in a rural
village in Country X from 2001 through 2009.

Application
•Analysis, conclusion, distribution, and timely use
of epidemiologic information to protect the health
of the population
•Example: As a result of the Country X Study,
free cervical cancer screening programs were
implemented. They targeted women living in
remote areas in hopes of finding women with
cervical cancer at an earlier stage of cancer in
order to prevent death.

• To measure frequency of disease – Quantify
disease
• To assess distribution of disease
– Who is getting disease?
– Where is disease occurring?
– When is disease occurring?
• To form hypotheses about causes and
preventive factors
• To identify determinants of disease
– Hypotheses are tested using epidemiologic
studies

EPIDEMIOLOGIC ASSUMPTIONS
• Diseases and other health-related events do
not occur at random
• Diseases and other health-related events
usually have causal and preventive factors that
can be found

Approach/
Consideration
Clinical Medicine Epidemiology
Focus Individuals
Main Goal Diagnosis and
treatment
Questions What is wrong with
this patient?
Treatment What treatment is
appropriate for this
patient?
Who is involved? Physician,
laboratorian, nurse,
and others

APPROACHES IN MEDICINE VS.
EPIDEMIOLOGY: FOCUS
Approach/
Consideration
Focus Individuals Populations
treatment
Questions What is wrong with this
patient?
appropriate?
Who is involved? Physician, laboratorian,
nurse, and others

APPROACHES IN MEDICINE VS.
EPIDEMIOLOGY: MAIN GOAL
Approach/
Consideration
treatment
Prevention and control
patient?
appropriate?
nurse, and others

Approach/
Consideration
treatment
patient?
What are the leading
causes of death or
disability in this
population? Risk factors?
appropriate?
nurse, and others

Approach/
Consideration
treatment
patient?
causes of death or
disability in this
appropriate?
What can be done to
reduce or prevent disease
or risk factors?
nurse, and others

Approach/
Consideration
treatment
patient?
causes of death or
disability in this
appropriate?
What can be done to
reduce or prevent disease
or risk factors?
nurse, and others
Epidemiologists,
statisticians, and others
from diverse disciplines

1. Descriptive
Epidemiology
2. Analytic
Epidemiology

• Studies the pattern of health events and their
frequency in populations in terms of:
‒ Person
‒ Place
‒ Time
• Purpose:
‒ To identify problems for further study
‒ To plan, provide, and evaluate health services

• Studies the association between risk factors
and disease
• Purpose:
‒ To determine why disease rates are high (or low) in
a particular group

PUBLIC HEALTH
MANAGEMENT CYCLE
25
2. Implement
Intervention
1. Form
Objective
4. Revise
Program
3. Measure
Impact

EPIDEMIOLOGY IN THE
PUBLIC HEALTH
MANAGEMENT CYCLE
26
2. Implement
Intervention
1. Form
Objective
4. Revise
Program
3. Measure
Impact
Epidemiology

 Public Health Surveillance
 Investigation
 Data Analysis
 Intervention
 Evaluation
 Communication
 Management and Teamwork

Ongoing, systematic collection, analysis, and
interpretation of health-related data essential to
the planning, implementation, and evaluation of
public health practice, closely integrated with the
timely dissemination of these data to those
responsible for prevention and control.
CDC’s National Notifiable Diseases Surveillance System (NNDSS) Website

• Describe the distribution of a health condition or
event in a community
• Create a hypothesis about what causes or
protects against disease or injury
• Learn about factors thought to be associated
with disease
• Assess associations between risk factors and
disease, using statistical methods
• Interpret results and disseminate information

Community
Clinical Staff
Sanitarians
Laboratory
Technicians
Public Health
Officials
Epidemiologist

1. Name at least four types of NCDs
2. Name at least four characteristics of NCDs

1. Name at least four types of NCDs.
cardiovascular disease, cancer, diabetes,
chronic lung disease, chronic neurologic
disorders, arthritis, musculoskeletal disorders
2. Name at least four characteristics of NCDs
complex etiology, multiple risk factors, long
latency period, non-contagious origin,
prolonged course of illness, functional
impairment or disability, incurability

3. What are at least three examples of modifiable
risk factors?
4. What are at least three examples of non-
modifiable risk factors?

REVIEW: ANSWERS 3-4
3. What are at least three examples of modifiable
risk factors? alcohol use, smoking, poor diet,
physical inactivity, high blood pressure, high
blood glucose
4. What are at least three examples of non-
modifiable risk factors? age, race, gender,
family history

REVIEW: QUESTION 5
5. How do NCDs and communicable diseases
differ?

5. How do NCDs and communicable diseases
differ?
a. Communicable disease occurrence depends upon
the presence / absence of disease already
occurring in that population; For NCDs, all disease
events are generally independent of one another.
b. For NCDs, the risk of disease largely depends on
population characteristics and other health
behaviors; Communicable disease can also be
influenced by these characteristics, but they have
properties that contribute to whether an exposed
individual will become infected.

6. What questions does epidemiology answer?
7. What are two approaches of epidemiology?
8. What are the four main roles of epidemiology in
the Public Health Management Cycle?

REVIEW: ANSWERS 6-8
6. What questions does epidemiology answer?
Who? What? When? Where? Why? How?
7. What are two approaches of epidemiology?
descriptive and analytic epidemiology
8. What are the four main roles of epidemiology in the
Public Health Management Cycle? form objectives,
implement interventions, measure impact, revise
programs

REVIEW: QUESTION 9
9. What are the functions of epidemiology?

REVIEW: ANSWER 9
9. What are the functions of epidemiology?
1. Public health surveillance
2. Investigation
3. Data analysis
4. Intervention
5. Evaluation
6. Communication
7. Management and teamwork

Definition
Noncommunicable diseases (NCDs), also
known as chronic diseases, are not passed
from person to person. They are of long
duration and generally slow progression.
(WHO, 2011)

Chronic conditions that do not result from an
(acute) infectious process and hence are “not
communicable.”
A disease that has a prolonged course, that
does not resolve spontaneously, and for which
a complete cure is rarely achieved.
McKenna, et al, 1998

• Chronic conditions are characterized by the
following:
– Do not result from an (acute) infectious process
– Are “not communicable”
– Cause premature morbidity, dysfunction, and
reduced quality of life
– Usually develop and progress over long periods
– Often initially insidious
– Once manifested there is usually a protracted period
of impaired health

In some definitions, NCDs also include:
•Chronic mental illness
•Injuries, which have an acute onset, but may be
followed by prolonged convalescence and
impaired function

• Complex etiology (causes)
• Multiple risk factors
• Long latency period
• Non-contagious origin (non-communicable)
• Prolonged course of illness
• Functional impairment or disability
• Incurability
• Insidious onset

http://www.who.int/gho/ncd/mortality_morbidity/en/index.html
• Cardiovascular disease (Coronary heart
disease, Stroke)
• Cancer
• Chronic lung disease
• Diabetes
• Chronic neurologic disorders (Alzheimer’s,
dementias)
• Arthritis/Musculoskeletal diseases
• Unintentional injuries (e.g., from traffic crashes)

LEADING CAUSES OF ATTRIBUTABLE
GLOBAL MORTALITY AND BURDEN OF
DISEASE, 2004
Attributable Mortality Attributable DALYs
http://who.int/healthinfo/global_burden_disease/GBD2004ReportFigures.ppt

Global Trends Causes of Deaths
Projected Deaths in 2015 and 2030
0
http://www.who.int/healthinfo/global_burden_disease/GBD_report_2004update_part2.pdf
5
10
15
20
25
30
Deaths
(millions)
2004 2015 2030
High income
2004 2015 2030
Middle income
2004 2015 2030
Low income
Mat//peri/nutritional
Other infectious
HIV, TB, malaria
CVD’s
Cancers
Other NCDs
Other unintentional
Road traffic accidents
Intentional injuries

Merriam-Webster Communicable Disease Definition Website
• An infectious disease transmissible (as from
person to person) by direct contact with an
affected individual or the individual's discharges
or by indirect means (as by a vector)
• Examples:
‒ Measles
‒ Dengue
‒ Typhoid

• How do they differ
regarding:
– Infectiousness?
– Risk of Disease?

(Principles of Epidemiology, CDC, 2006)
“An aspect of personal behavior or lifestyle, an
environmental exposure, or a hereditary
characteristic that is associated with an increase in
the occurrence of a particular disease, injury, or
other health condition.”

A risk factor that can be reduced or controlled by
intervention, thereby reducing the probability of
disease.
The WHO has prioritized the following four:
•Physical inactivity
•Tobacco use
•Alcohol use
•Unhealthy diets (increased fat and sodium, with
low fruit and vegetable intake).

A risk factor that cannot be reduced or controlled
by intervention, for example:
•Age
•Gender
•Race
•Family history (genetics)

• “Metabolic" refers to the biochemical
processes involved in the body's normal
functioning
• Behaviors (modifiable risk factors) can lead to
metabolic/physiologic changes.
• WHO has prioritized the following four
metabolic risk factors:
o Raised blood pressure
o Raised total cholesterol
o Elevated glucose
o Overweight and obesity

• Cardiovascular disease (CVD) is a group of disorders
of the heart and blood vessels, and may include:
Coronary heart
disease
Disease of the blood vessels supplying the
heart muscle
Cerebrovascular
disease
(Stroke)
Disease of the blood vessels supplying the
brain
Peripheral arterial
disease
Disease of blood vessels supplying the arms
and legs
Congenital heart
disease
Malformations of heart structure existing at
birth

• CVDs are the #1 cause of death globally.
• An estimated 17.3 million people died from CVDs in
2008. (30% of all global deaths)
• 7.3 million were due to coronary heart disease
• 6.2 million were due to stroke
• Over 80% CVD deaths occur in low- and middle- income
countries.
• By 2030, almost 25 million people will die from CVDs.
http://www.who.int/cardiovascular_diseases/en/
CARDIOVASCULAR DISEASE

Overview of NCD’s and Risk Factors
Major modifiable risk factors
-High blood pressure
-Abnormal blood lipids
-Tobacco use
-Physical inactivity
-Obesity
-Unhealthy diet (salt)
-Diabetes
Other modifiable risk factors
-Low socioeconomic status
-Mental ill health (depression)
-Psychosocial stress
-Heavy alcohol use
-Use of certain medication
-Lipoprotein(a)
Non-modifiable risk factors
-Age
-Heredity or family history
-Gender
-Ethnicity or race
“Novel” risk factors
-Excess homocysteine in blood
-Inflammatory markers (C-
reactive protein)
-Abnormal blood coagulation
(elevated blood levels of
fibrinogen)

DIABETES: DEFINITION
• Diabetes is a disorder of metabolism— the way the
body uses digested food for growth and energy.
• There are 4 types: Type 1, Type 2, Gestational, and
Pre-Diabetes (Impaired Glucose Tolerance).
• Type 2 is caused by modifiable risk factors and is
the most common worldwide.
• >90% of all adult diabetes cases are Type 2
1. http://www.who.int/mediacentre/factsheets/fs312/en/
2. National institute of Diabetes and Digestive and Kidney Diseases, 2012

http://www.drugs.com/health-guide/type-1-diabetes-mellitus.html

• 347 million people worldwide have diabetes.
• In 2004, an estimated 3.4 million people died from consequences of
high blood sugar.
• More than 80% of diabetes deaths occur in low- and middle-income
countries.
• WHO projects that diabetes deaths will increase by two thirds
between 2008 and 2030.
• Healthy diet, regular physical activity, maintaining a normal body
weight and avoiding tobacco use can prevent or delay the onset of
type 2 diabetes.
1. http://www.who.int/mediacentre/factsheets/en/ 2.http://www.idf.org/regions

Major modifiable Risk Factors
-Unhealthy diets
-Physical Inactivity
-Obesity or Overweight
-High Blood Pressure
-High Cholesterol
Other Modifiable Risk Factors
-Low socioeconomic status
-Heavy alcohol use
-Psychological stress
-High consumption of sugar-
sweetened beverages
-Low consumption of fiber
Non-modifiable Risk Factors
-Increased age
-Family history/genetics
-Race
-Distribution of fat
Other Risk Factors
-Low birth weight
-Presence of autoantibodies

• Generic term for a large group of diseases that can
affect any part of the body.
• “Rapid creation of abnormal cells that grow beyond
their usual boundaries, and which can then invade
adjoining parts of the body and spread to other
organs.” (WHO, 2012)
• Benign tumors
• Malignant tumors

http://www.cancer.gov/cancertopics/cancerlibrary/what-is-cancer

GLOBAL BURDEN OF CANCER
http://www.who.int/mediacentre/factsheets/fs297/en/index.html
• 7.6 million people died from cancer in 2008.
• 70% of all cancer deaths occur in low- and middle-
income countries.
• Deaths from cancer are estimated to reach 13.1
million by 2030.
• About 30% of cancers are attributable to behavior
risk factors.

Cancer Epidemiology
Estimated age-standardised incidence and mortality rates: total population
http://globocan.iarc.fr/

CERVICAL CANCER: DEFINITION
Cancer of the female reproductive system:
•Two cell types present (squamous and glandular)
•Tend to occur where the two cell types meet
•99% of cases linked to genital infection with human
papillomavirus (HPV)
TAP Pharmaceuticals, “Female Reproductive Systems

CERVICAL CANCER
ESTIMATED AGE - STANDARDIZED RATES (WORLD)
PER 100,000

CERVICAL CANCER:
RISK FACTORS
• Human papilloma virus infection (HPV)
• Smoking
• Immune Deficiencies
• Poverty
• No access to PAP screening
• Family history of cervical cancer

LUNG CANCER: DEFINITION
• Cancer that forms in tissues of the lung, usually in
the cells lining air passages
• Leading cause of cancer death globally,1.37 million
deaths in 2008
• Affects more men than women
• Two main types:
– Small cell lung cancer
– Non-small cell lung cancer

LUNG CANCER
INCIDENCE AND MORTALITY IN 2008: BOTH SEXES
Source: http://globocan.iarc.fr/

LUNG CANCER: RISK FACTORS
• Smoking cigarettes, pipes, or cigars - now or in the
past
• Being exposed to second-hand smoke
• Being treated with radiation therapy to the breast or
chest
• Being exposed to asbestos, radon, chromium,
nickel, arsenic, soot, or tar
• Living where there is air pollution

BREAST CANCER: DEFINITION
• Cancer that forms in the tissues of the breast,
usually in the ducts or in the lobules
• Occurs commonly in women, rarely occurs in men
• 1 of 8 women will be diagnosed with breast cancer
in her lifetime.

BREAST CANCER:
RISK FACTORS
• Hormone therapies
• Weight and physical activity
• Race
• Genetics or family history
– BRCA1 and BRCA2 genes
• Age is the most reliable risk factor!
– Risk increases with age

PROSTATE CANCER
• 2nd most common
cancer among men
• The cancer develops
inside of the prostate
gland.
• Risk factors: age,
race, obesity, weight
gain
Mortality
Rate
Year
http://globocan.iarc.fr/factsheet.asp

PROSTATE CANCER
INCIDENCE AND MORTALITY IN 2008: TOTAL POPULATION

COLORECTAL CANCER
http://www.mayoclinic.com/health/colon-cancer/DS00035
• 3rd most common type of cancer
• Forms in the lower part of the digestive system
(large intestine)
• Risk Factors include:
– Aging
– Black race
– Unhealthy diet and low exercise
– Diabetes
– Family history of colorectal cancer

COLORECTAL CANCER

GLOBAL BURDEN OF
CHRONIC RESPIRATORY
DISEASE
• A leading cause of death
• High under-diagnoses rates
• 90% of deaths occur in low-income countries
http://www.who.int/respiratory/about_topic/en/index.html

CHRONIC RESPIRATORY DISEASES:
SHARED RISK FACTORS
Genes
Infections
Socio-economic
status
Aging
Populations
http://www.goldcopd.org/other-resources-gold-teaching-slide-set.html

• Chronic obstructive pulmonary disease
• COPD – term used for lung diseases that prevent
proper lung airflow
• Chronic bronchitis, emphysema
• More than just “smoker’s cough”

COPD: BURDEN
http://www.who.int/respiratory/copd/burden/en/index.html
• Accurate epidemiologic data on COPD prevalence,
morbidity, and mortality are difficult and expensive
to collect.
• 65 million people worldwide have moderate to
severe COPD.
• More than 3 million people died of COPD in 2005
(3% of all deaths globally).
• Almost 90% of COPD deaths occur in low- and
middle-income countries.

CHRONIC RESPIRATORY
DISEASES: ASTHMA
• Recurrent attacks of “breathlessness and
wheezing” (WHO, 2012)
• A gradient of severity
• Can cause sleepiness, fatigue
• Low fatality rates, but often underdiagnosed
• 235 million people affected

CHRONIC RESPIRATORY
DISEASES: ASTHMA
Medications can help control asthma
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001196/

WHY RISK FACTORS?
• Surveillance for non-communicable disease can be
difficult because of:
• Lag time between exposure and health condition,
• More than one exposure for a health condition, and
• Exposure linked to more than one health condition.
• Interventions that target risk factors are needed to
prevent disease.

DEATHS ATTRIBUTED TO 19 LEADING
RISK FACTORS, BY COUNTRY INCOME
LEVEL, 2004
WHO Global Health risks report

TOBACCO USE
• Tobacco kills up to half of its users.
• Tobacco kills nearly 6 million people each year.
• Annual death toll could rise to more than 8
million by 2030.
• Nearly 80% of the world’s 1 billion smokers live
in low- and middle-income countries.

GLOBAL ADULT TOBACCO
SURVEY
http://www.cdc.gov/tobacco/global/gtss/tobacco_atlas/index.htm

TOBACCO USE: HEALTH
EFFECTS
Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Medicine, 2006,
3(11): e442.

CONT.
• Cancer
• Coronary heart disease
• Diseases of the lungs
• Peripheral vascular
disease
• Stroke
• Fetal complications and
stillbirth
Among smokers: • Second-hand smoke
causes:
•Heart disease,
including heart attack
•Lung cancer

GLOBAL CHANGES IN
DIET
http://www.pitt.edu/~super4/41011-42001/41171.pdf
• Most countries have increased overall daily
consumption of:
• Daily calories,
• Fat and meats, and
• Energy dense and nutrient-poor foods such
as:
– Starches
– Refined sugars
– Trans-fats

UNHEALTHY DIET: HEALTH
EFFECTS
• Coronary heart disease
• Stroke
• Cancer
• Type 2 diabetes
• Hypertension
• Diseases of the liver and gallbladder
• Obesity

GLOBAL CHANGES IN
PHYSICAL ACTIVITY
• 31% of the world’s population does not get enough
physical activity.
• Many social and economic changes contribute to
this trend:
• Aging populations,
• Transportation, and
• Communication technology.
1. http://www.cdc.gov/physicalactivity/everyone/guidelines/adults.html
2. http://www.sciencedirect.com/science/article/pii/S0140673612608988

CONT.
Lee IM, Shiroma EJ, Lobelo F, Puska P, Blair SN, Katzmarzyk PT; Lancet Physical Activity Series Working Group.
Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life
expectancy. Lancet. 2012 Jul 21;380(9838):219-29

PHYSICAL ACTIVITY:
HEALTH EFFECTS
Reduces:
High blood
pressure
Adverse lipid
profile
Arthritis pain
Psychiatric
issues
Reduces risk of:
Type 2 diabetes
Certain cancers
Heart attacks
Stroke
Falls
Early death
http://www.health.gov/paguidelines/factsheetprof.aspx

GLOBAL ALCOHOL CONSUMPTION
• 11.5% of all global drinkers are episodic, heavy
users.
• 2.5 million people die from alcohol
consumption per year
• The majority of adults consume at low-risk
levels.
• Estimated worldwide consumption of alcohol
has remained relatively stable.
http://www.who.int/substance_abuse/publications/global_alcohol_report/msbgsruprofiles.pdf

CONT.
http://www.who.int/substance_abuse/publications/global_alcohol_report/en/index.html

HARMFUL USE OF ALCOHOL:
DEFINITION
Excessive drinking, per day
• Heavy drinking – on average
> >
• Binge drinking – single occasion
≥ ≥

HARMFUL USE OF ALCOHOL:
EFFECTS
• Diminished brain
function
• Loss of body heat
• Fetal damage
• Risk for unintentional
injuries
• Risk for violence
• Coma and death
Immediate effects: Long-term effects:
• Liver diseases
• Cancers
• Hypertension
• Gastrointestinal
disorders
• Neurological issues
• Psychiatric issues

METABOLIC RISK FACTORS
What are the four metabolic risk factors?
1. Raised Blood Pressure (Hypertension)
2. Raised Cholesterol
3. Raised Blood Glucose
4. Overweight and Obesity

RAISED BLOOD PRESSURE
 Hypertension
 (Systolic)/(Diastolic) in mm of Hg (mercury)
 Systolic = amount of force your arteries use when the
heart pumps
 Diastolic = amount of force your arteries use when the
heart relaxes
Measurement Normal Pre-Hypertensive Hypertensive
Systolic
mmHg
<120 120-139 140+
Diastolic
mmHg
<80 80-89 90+

HIGH BLOOD PRESSURE
1. US Department of Health & Human Services, National Heart, Lung, and Blood
2. http://gamapserver.who.int/gho/interactive_charts/ncd/risk_factors/blood_pressure_prevalence/atlas.html

RAISED BLOOD PRESSURE:
HEALTH EFFECTS
• Leading risk factor for stroke
• Major risk factor for coronary heart disease
• In some age groups, the risk of CVD doubles for
each increment of 20/10 mmHg of blood pressure
• Other complications of raised blood pressure:
– Heart failure
– Peripheral vascular disease
– Renal impairment
– Retinal hemorrhage
– Visual impairment

HYPERTENSION AND EXCESSIVE
SODIUM INTAKE
• Sodium, through hypertension, is a major cause of
cardiovascular disease deaths and disability.
• About 10% of cardiovascular disease is caused by
excess sodium intake.
• 8.5 million deaths could be prevented over 10 years
if sodium intake were reduced by 15%.

SOURCES OF SODIUM
• People are unaware of how much dietary sodium
they are eating.
• In the U.S. 75% of sodium consumed comes from
processed and restaurant foods.
• In China and Japan, 75% of sodium consumed
comes from cooking with high sodium products.

RECOMMENDATIONS AND
ACTUAL INTAKES WHO/PAHO
• Recommendations
• A population salt intake of less than 5 grams or
approximately 2,000 milligrams of sodium, per person per
day is recommended to reach national targets or in their
absence. This level was recommended for the prevention
of cardiovascular diseases.
• Actual Intake
• Latest global estimates show that average sodium
intake varies from 2,000 to 7,200 milligrams of sodium
per person per day.

RAISED TOTAL CHOLESTEROL
HDL: High density lipoproteins; often called “good cholesterol”
LDL: Low density lipoproteins; often called “bad cholesterol”
VLDL: Very low density lipoproteins; has highest amount of
triglycerides
Triglycerides: Type of fat found in your blood (stored in fat cells)

GLOBAL BURDEN OF RAISED
TOTAL CHOLESTEROL
• In 2008, global prevalence of raised total
cholesterol among adults (≥ 5.0 mmol/l) was 39%
(37% for males and 40% for females).
• Estimated to cause 2.6 million deaths.

RAISED TOTAL
CHOLESTEROL:
HEALTH EFFECTS
http://www.who.int/gho/ncd/risk_factors/cholesterol_text/en/
• Increases risks of heart disease and stroke
• Globally, 1/3 of ischaemic heart disease is attributable to
high cholesterol
• A 10% reduction in serum cholesterol in men aged 40 has
been reported to result in a 50% reduction in heart disease
within 5 years
• A 10% reduction in serum cholesterol in men aged 70
years can result in an average 20% reduction in heart
disease occurrence in the next 5 years

ELEVATED GLUCOSE
 Sugar produces fuel and energy for our cells
 Insulin helps control the amount of glucose in our bodies

GLOBAL BURDEN OF ELEVATED
GLUCOSE
• In 2004, it was estimated that elevated glucose
resulted in 3.4 million deaths (5.8% of all deaths).
• Globally, approximately 9% of adults aged 25 and
over had elevated blood glucose in 2008.

ELEVATED GLUCOSE:
HEALTH EFFECTS
• Elevated glucose levels can lead to type 2
diabetes.
• Diabetes: leading cause of renal failure
• Lower limb amputations are at least 10 times more
common in people with diabetes than in non-diabetic
people
• Raised glucose is a major cause of heart disease
and renal disease.

OVERWEIGHT AND OBESITY
• Overweight and obesity are defined as ''abnormal or
excessive fat accumulation that presents a risk to
health.” (1)
• BMI - the Body Mass Index
BMI = (weight in kg)/(height in meters, squared)
- Between 25 and 29.9 indicates overweight
- 30 or higher indicates obesity
• Skinfold Thickness Test
• Waist-to-Hip Circumference Ratio
– Men > 102 cm are considered high risk
– Women > 88 cm are considered high risk
1. http://www.who.int/dietphysicalactivity/childhood_what/en/index.ht

OVERWEIGHT AND OBESITY:
GLOBAL BURDEN
http://www.who.int/healthinfo/global_burden_disease/2004_report_update/en/index.html
• Worldwide, obesity has more than doubled since 1980.
• In 2008, more than 1.4 billion adults, 20 and older, were
overweight.
– Of these, 200 million men and nearly 300 million women were
obese.
• 65% of the world’s population live in countries where the
mortality associated with overweight and obesity is higher
than the mortality associated with underweight.
• Globally, in 2010 the number of overweight children under the
age of five was estimated to be over 42 million.
– Close to 35 million of these are living in developing countries.

OVERWEIGHT AND OBESITY:
HEALTH
EFFECTS
• Environment, lifestyle, genetics, and other
factors contribute to each individual’s risk for
being overweight or obese.
• Increases risk of coronary heart disease, type 2
diabetes, and hypertension
• Large economic consequences for many
countries
• Resource:
http://www.thelancet.com/series/obesity
http://www.thelancet.com/series/obesity

2012 WHO GLOBAL
TARGETS: REDUCING RISK
FACTORS
http://www.who.int/nmh/events/2012/4November2012_PPT_RevPaper_TA.pdf

STOMACH CANCER:
DEFINITION
• There are many forms of stomach cancer
• Adenocarcinoma- cell type lining the stomach

STOMACH CANCER

STOMACH CANCER:
RISK FACTORS
 Smoking
 Family history of stomach cancer
 Helicobacter pylori infections, ulcers or polyps
 Diet
– High salt foods, smoked foods, and
pickled foods

• Cancer that forms in the liver or spreads from
the liver to other areas of the body
• Few early signs of liver cancer
• Several types of liver cancer exist

• Sex
• Age
• Chronic hepatitis infections
• Diabetes
• Cirrhosis
• Heavy alcohol consumption
• Obesity

NATIONAL NCD
PROGRAMMES AND
CHALLENGES

OUTLINE
Understand the following regarding NPCDCS and
NCD program in India
• Policy and Strategic framework for implementation
• Objectives, Strategies and Activities
• Infrastructure
• Areas of integration with other health Programmes
Progress
• Challenges

 National Programme for prevention & Control of Cancer,
Diabetes, Cardiovascular Diseases & stroke (NPCDCS)
 National Programme For Control Of Blindness & Visual
Impairment(NPCBVI)
 National Programme for the Prevention & Control of Deafness
(NPPCD)
 National Tobacco Control Programme (NTCP)

POLICY & STRATEGIC FRAMEWORK FOR
IMPLEMENTATION
(AS PERCEIVED IN 2010 AT THE TIME OF LAUNCH IN 100 DISTRICTS)
 In India, the estimated deaths due to NCDs in 2008 were 5.3 million
 The overall prevalence of diabetes, hypertension, ischemic heart
diseases (IHD) and stroke in India was 62.47, 159.46, 37.00 and 1.54
respectively per 1000 population.
 It was estimated that there were about 28 lakh cases of different type of
cancers in the country with occurrence of about 11 lakh new cases and
about 5 lakh deaths annually.
 Govt. of India had already launched a flagship program called National
Health Mission (NHM) in 2005 with the objective of expanding access to
quality health care to rural populations.
 Different States also had initiated some of the activities for prevention
and control of non-communicable diseases (NCDs) especially cancer,
diabetes, CVDs and stroke.
 In this scenario, the Central Govt. proposed to supplement their efforts
by providing technical and financial support through NPCDCS.

BACKGROUND ABOUT
NATIONAL HEALTH MISSION (NHM)
The crucial strategies under NHM were
• Integration of Family Welfare and National Disease Control
Programmes under an umbrella approach for optimization of
resources and manpower;
• Strengthening of outreach services by incorporation of village
health worker called ASHA;
• Efforts for communitization of services through formation of
Health and Sanitation Committees at village, block and district
level;
• Registering Rogi Kalyan Samiti (Patient Welfare
Committee)/Hospital Management Committee for improving
hospital management;
• Strengthening and upgrading the public health infrastructure to
Indian Public Health Standards (IPHS); and
• Consolidation of the District Level Programme Management Unit
through the induction of professionals.

• For optimization of scarce resources and provision of seamless services to
the end customer/patients and ensuring long term sustainability of
interventions.
• Sharing administrative and financial structure of NHM became a crucial
programme strategy.
• The NCD cell at various levels would ensure implementation and supervision.
• Simultaneously, it would attempt to create a wider knowledge base in the
community for effective prevention, detection, referrals and treatment
strategies through convergence / linkage with the ongoing interventions:
• National Health Mission (NHM) including National Tobacco Control
Programme (NTCP), National Mental health Programme and National
Programme for Health Care of Elderly (NPHCE)
• Convergence with other programmes dealing with (i) communicable
diseases like TB,(ii) RCH, (iii) Adolescent /School Health etc.

• Health promotion through behavior change with involvement of
community, civil society, community based organizations, media etc.
• Opportunistic screening at all levels in the health care delivery
system from subcentre and above for early detection of diabetes,
hypertension and common cancers. Outreach camps were also
envisaged.
• To build capacity at various levels of health care for prevention, early
diagnosis, treatment, IEC/BCC, operational research and
rehabilitation.
• To support for diagnosis and cost effective treatment at primary,
secondary and tertiary levels of health care.
• To support for development of database of NCDs through
Surveillance System and to monitor NCD morbidity and mortality and
risk factors.

• Health promotion, awareness generation and promotion of
healthy lifestyle
• Screening and early detection
• Timely, affordable and accurate diagnosis
• Access to affordable treatment
• Rehabilitation

CONT.
• The programme division at the national level would develop broad
guidelines and strategy for implementation of different components of
the programme.
• The States may adopt and modify these guidelines as per their need
and circumstances for implementation of the programme.
• Involvement of community, civil society and private sector partnership
would be vital, and suitable guidelines would be made for the same.

• Establishment/Strengthening of Health infrastructure
• Human Resource development
• Integration with AYUSH
• Public private partnership
• Research and surveillance
• Monitoring & evaluation

CONT.
• Recent initiatives:
• Universal NCD Screening (Populations based screening)
• IT software (NCD Application) developed for recording and reporting
• Inclusion of COPD & CKD interventions under programme
• Expected Outcome: establish a comprehensive sustainable
system for reducing rapid rise of NCDs, disability as well as deaths
due to NCDs

• Package of services enlisted for various government health facilities
• Key monitoring indicators and targets set
• Institutional framework for the implementation of NPCDCS activities
prepared
• Integration with NHM, State Health Society and District Health Society
• Technical resource groups planned
• Establishment/Strengthening of Health infrastructure
• PHCs, SCs, CHCs, DH, NCD Clinics, Cardiac Care Units, Support for Cancer and
Lab strengthening

CONT.
• Management structure:
• National NCD Cell, State NCD Cell and District NCD Cell
• Financial guidelines prepared along with HR-TORs and indicative
list of equipment & drugs
• Different types of forms and reporting formats also designed
• New components added later such as guidelines for one time
financial assistance under Tertiary Cancer Care Scheme

National
NCD Cell
State
NCD Cell
District
NCD Cell
District
NCD Clinic
CHC NCD
Clinic
PHC /
Health & Wellness Centres
Sub-centre /
Health & Wellness Centres
Cardiac
&
Stroke
Care
Unit
Day Care
Cancer
Centre

2010:
Program
launched in
100 districts of
21 States
2013-14:
•Rolled out in 36
States/UTs
•Integration with
NHM
•TCCC Scheme
initiated
2015-16:
Total 468
districts
approved
2017-18:
Total 669 districts
approved
2018-19:
Total 708
districts
approved

SCALE-UP OF INFRASTRUCTURE
(CUMULATIVE NO. OF FACILITIES
ESTABLISHED)

• Guidelines and Training Modules for different category of
personnel:
• Program manager at State & District level, MO, SN, ANM, ASHA,
Counselors, MPWs, CHWs, etc.
• IEC material, flip charts, etc to be used at different levels
• Guidelines and training manual on integration of ayurveda in NPCDCS
• Operational guidelines on integration of homeopathy in NPCDCS

• Training manual on integration of unani medicine in NPCDCS
• Guidelines for Population based screening
• National framework for joint TB-Diabetes collaborative activities
• National multi sectoral action plan for prevention and control of
common NCDs

IEC & Advocacy:
 Strong advocacy & IEC needed to raise public
awareness and develop strategies to modify risk
factors
Finance & Logistics:
 Irregular supply of drugs/consumables in NCD clinics:
an issue in most States
 On one hand there is low Central budget allocation for
NCD, and on the other hand, there is underutilization of
NPCDCS budget in many States

Monitoring & Evaluation:
 Regular Hand-holding supervision by Programme
Managers
 Robust ‘Data-base of NCDs’ needed to understand
landscape of NCDs & associated risk factors, so as to
plan evidence-based local response
 Management Information System is the need of the
hour: Online/Web-based reporting system
Human Resource:
 Recruitment of Staff and their Capacity Building under
NPCDCS at all levels
 State/District Nodal Officer has many additional
charges
 Under HR-rationalization policy of NHM, dedicated
contractual manpower for NPCDCS provided for
Service Delivery at NCD Clinics, as per case-load and
need
CONT.

 Launched: 1976
 Funding: 100% Centrally Sponsored
 Goal: Reduce blindness prevalence from 1.4% to
0.3%
 Progress:
 2001-02: 1.1% blindness prevalence
 2006-07: Reduced to 1%

Primary Goals:
 Reduce blindness backlog
 Improve eye health strategy and prevention

https://indiavisionatlasnpcb.aiims.edu/npcb-vi/

1. Identification & Treatment:
 Primary, secondary, tertiary levels
2. Strengthen Eye Health Strategy:
 Comprehensive eye care services
3. Upgrade RIOs:
 Centers of excellence in ophthalmology
4. Develop Human Resources & Infrastructure:
 High-quality eye care in all districts
5. Enhance Community Awareness:
 Emphasis on preventive measures
6. Expand Research:
 Focus on prevention of blindness
7. Voluntary Organization Participation:
 Involve private practitioners in eye care

NATIONAL PROGRAMME
FOR THE PREVENTION &
CONTROL OF DEAFNESS
(NPPCD)

• Hearing loss is the most common sensory deficit in humans
today.
• Approximately 63 million people in India suffer from
Significant Auditory Impairment (WHO).
• Estimated prevalence: 6.3% in the Indian population.
• NSSO survey (2001): 291 persons per one lakh population
have severe to profound hearing loss.
• A large percentage of affected individuals are children aged
0 to 14 years.
• Hearing impairment in young Indians leads to significant
physical and economic productivity loss.
• Many more suffer from milder degrees of hearing loss and
unilateral hearing loss.

1. To prevent the avoidable hearing loss on account of
disease or injury.
2. Early identification, diagnosis and treatment of ear
problems responsible for hearing loss and deafness.
3. To medically rehabilitate persons of all age groups,
suffering with deafness.
4. To strengthen the existing inter-sectoral linkages for
continuity of the rehabilitation programme, for persons with
deafness.
5. To develop institutional capacity for ear care services by
providing support for equipment and material and training
personnel.

1. Manpower Training & Development – Training from medical
college level specialists (ENT and Audiology) to grass root
level workers.
2. Capacity Building – for the district hospital, CHC and PHC in
respect of ENT/Audiology infrastructure.
3. Service Provision Including Rehabilitation – Screening
camps for early detection of hearing impairment and deafness,
management of hearing and speech impaired cases and
rehabilitation (including provision of hearing aids).
4. Awareness Generation Through IEC Activities – For early
identification of hearing impaired, especially children, to enable
timely management and remove the stigma attached to
deafness.
5. Monitoring and Evaluation

1. Large scale direct benefit of various services like prevention, early
identification, treatment, referral, rehabilitation etc. for hearing impairment and
deafness as the primary health center / community health centers / district
hospitals largely cater to their need.
2. Decrease in the magnitude of hearing impaired persons.
3. Decrease in the severity/ extent of ear morbidity or hearing impairment in
large number of cases.
4. Improved service network for persons with ear morbidity/hearing
impairment in the states and districts covered under the project.
5. Awareness creation among health workers/grassroot level workers through
primary health centre medical officers and district officers.
6. Larger community participation to prevent hearing loss through panchayati
raj institutions, mahila mandals, village bodies and creation of a collective
responsibility framework.
7. Leadership building in primary health centre medical officers to help create
better sensitization in the grassroots level.
8. Capacity building at district hospitals to ensure better care.
9. State of the art department of ENT at the medical colleges in the
state/union territory under the project.

NATIONAL TOBACCO
CONTROL PROGRAMME
(NTCP)

• Launched in 2007-08 during the 11th Five-Year Plan
• Aims:
- Create awareness about harmful effects of tobacco
- Reduce production and supply of tobacco products
- Ensure effective implementation of COTPA, 2003
- Help people quit tobacco use
- Implement WHO Framework Convention on Tobacco
Control strategies

• 11th Five Year Plan: Implemented in 21 states covering
42 districts
• 12th Five Year Plan: Upscaled to reduce tobacco use
prevalence by 5%
• GATS 2009-2010: Baseline data indicating high tobacco
use
• GATS second round: 81 lakh (8.1 million) reduction in
tobacco users

• Training: Health/social workers, NGOs, school teachers,
enforcement officers
• IEC Activities
• School Programmes
• Monitoring tobacco control laws
• Coordination with Panchayati Raj Institutions
• Cessation facilities and pharmacological treatment at
district level

• Three-tier structure:
- National Tobacco Control Cell (NTCC) at Central level
- State Tobacco Control Cell (STCC) at State level
- District Tobacco Control Cell (DTCC) at District level
• Tobacco Cessation Services at District level

• Dedicated funds and manpower for implementation
• Integrated into Flexi-pool for Non-Communicable
Disease under NHM
• Implemented in all 36 States/Union Territories covering
612 districts

• Responsible for policy formulation, planning, implementation,
monitoring and evaluation
• Functions under the guidance of Joint Secretary, MoHFW
• Technical assistance by officers in Directorate General of Health
Services
• Activities:
- Public awareness campaigns
- Establishment of tobacco product testing laboratories
- Mainstreaming research on alternative crops and livelihoods
- Monitoring and evaluation

• Dedicated State Tobacco Control Cells
• Activities:
- State Level Advocacy Workshops
- Training of Trainers Programme
- Refresher training of DTCC staff
- Training on tobacco cessation for health care providers
- Law enforcers training/sensitization Programme

• Dedicated District Tobacco Control Cells
• Activities:
- Training of key stakeholders
- IEC activities
- School programmes
- Monitoring tobacco control laws
- Setting up and strengthening cessation facilities
- Coordination with Panchayati Raj Institutions

HALF-TRUTHS AND
MISUNDERSTANDINGS

HALF-TRUTHS AND
MISUNDERSTANDINGS: REALITY
Reality: death is inevitable but
it does not need to be slow,
painful, or premature

Centers for Disease Control and Prevention (CDC). Overview of
NCD’s and Risk Factors. Atlanta, Georgia: Centers for Disease
Control and Prevention (CDC); 2013.

Non-Communicable Diseases and National Health Program (NCD)

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